CLINICAL CASES. Case 1: Mr. OA Mr. OA: Case Presentation 62-year-old lawyer Mild left knee pain for...
Transcript of CLINICAL CASES. Case 1: Mr. OA Mr. OA: Case Presentation 62-year-old lawyer Mild left knee pain for...
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CLINICAL CASES
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Case 1: Mr. OA
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Mr. OA: Case Presentation
• 62-year-old lawyer• Mild left knee pain for 3 month, but became
worse 1 week ago• No swelling• 1 week earlier: 2-hour walk in the countryside
2 days in a row• Walks 3–4 times a week• No current medications
OA
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Mr. OA: Discussion Question OA
WHAT ARE SOME POSSIBLE CAUSES OF MR. OA’S
JOINT PAIN?WHAT ADDITIONAL INFORMATION
WOULD YOU LIKE TO KNOW?
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Mr. OA: Pain History
• Where is the pain?– Diffuse but more pronounced medially
• Trigger:– Walk in the country, 2 hours, 2 days in a row– Morning stiffness that disappears after 30 minutes
• Swelling:– Not this time, but appears when he is more active– No locking or buckling
• Old surgery or deformation:– Medial meniscectomy of left knee 37 years ago
OA
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Mr. OA: Discussion Question OA
BASED ON THE INFORMATION COLLECTED, WHAT WOULD
YOU LOOK FOR ON THE PHYSICAL EXAM?
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Mr. OA: Targeted Examination
• Inspection:– Slight limp– Overweight– Mild genu varum– No swelling, atrophy or redness
• Mr. OA locates his pain with his hand in the anterior medial area of the knee
• Incomplete flexion on the affected side
OA
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Mr. OA: Targeted Examination (cont’d)
• Range of motion:– Incomplete flexion on the affected side– Normal extension
• Swelling:– Patellar tap: negative– Therefore, no effusion
• Palpation:– Medial joint-line tenderness, no pain elsewhere– Crepitus was detected in the left knee
• Hip examination: normal
OA
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Mr. OA: Discussion Question OA
WOULD YOU CONDUCT ANY FURTHER INVESTIGATIONS
SUCH AS LABORATORY TESTS
OR IMAGING?
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Mr. OA: Investigation
• X-ray of knee shows:– Multiple moderate osteophytes– Definite medial
joint space narrowing– Some sclerosis
OA
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Mr. OA: Discussion Question OA
WHAT WOULD BE YOUR DIAGNOSIS?
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Mr. OA: Diagnosis
• Osteoarthritis of the knee (medial compartment)
OA
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Mr. OA: Discussion Question OA
WHAT WOULD BE YOUR TREATMENT PLAN?
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Mr. OA: Treatment Plan
• Apply heat on local pain area• Physiotherapy or therapeutic exercise• Possibility of joint injection• Acetaminophen• nsNSAIDs/coxibs
OA
Coxib = COX-2-specific inhibitor; nsNSAID = non-specific non-steroidal anti-inflammatory drug
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Case 2: Mrs. RA
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Mrs. RA: Case Presentation
• 55-year-old legal secretary• Complains that she has had pain and swelling
of several hand joints for about 2 years, but these have become worse in the last 3 months
• Her joint pain and swelling is more severe in the morning and she has difficulty typing, but her symptoms get better in the afternoon
• She asks to be put on same medication as her husband who has osteoarthritis
RA
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Mrs. RA: Discussion Question RA
WHAT ADDITIONAL INFORMATION WOULD YOU LIKE TO KNOW?
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Physical Examination
• Her hand joints are swollen and tender, involving PIP and MCP
• Slight swelling and tender in both wrist• Symmetrical in both hands
RA
MCP = metacarpophalangeal; PIP = proximal interphalangeal
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Mrs. RA: Discussion Question RA
WOULD YOU CONDUCT ANY FURTHER INVESTIGATIONS SUCH
AS LABORATORY TESTS OR IMAGING?
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X-ray and Abnormal Lab Findings
• Osteoporosis around PIP joints and erosion of some PIP joints
• Her blood ESR and CRP were elevated• Her RF and anti-CCP antibody are positive
RA
CCP = cyclic citrullinated peptide; CRP = C-reactive protein; ESR = erythrocyte sedimentation rate; PIP = proximal interphalangeal; RF = rheumatoid factor
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Mrs. RA: Discussion Question RA
WHAT WOULD YOU TELL MRS. RA?
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What Mrs. RA’s diagnosis?
• Her diagnosis is rheumatoid arthritis
RA
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Mrs. RA: Discussion Questions RA
WHAT WOULD BE YOUR GOALS FOR MRS. RA?
WHAT WOULD BE YOUR TREATMENT PLAN?
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Mrs. RA: Treatment Plan
• You prescribe nsNSAID/coxib to manage the pain from the acute flare
• Refer Mrs. RA to rheumatologist to confirm diagnosis and initiate disease-modifying treatment
RA
Coxib = COX-2-specific inhibitor; nsNSAID = non-specific non-steroidal anti-inflammatory drug
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Case Template
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Patient Profile
• Gender: male/female• Age: # years• Occupation: Enter occupation• Current symptoms: Describe current symptoms
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Medical History
Comorbidities
• List comorbidities
Measurements
• BMI: # kg/m2
• BP: #/# mmHg• List other notable results of
physical examination and laboratory testsCurrent medications
• Describe any relevant social and/or work history
• List current medications
Social and Work History
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Discussion Questions
BASED ON THE CASE PRESENTATION, WHAT WOULD YOU CONSIDER IN YOUR DIFFERENTIAL DIAGNOSIS?WHAT FURTHER HISTORY WOULD
YOU LIKE TO KNOW?WHAT TESTS OR EXAMINATIONS
WOULD YOU CONDUCT?
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Pain History
• Duration: When did pain begin? • Frequency: How frequent is pain?• Quality: List descriptors of pain• Intensity: Using VAS or other tool• Distribution and location of pain: Where does
it hurt?• Extent of interference with daily activities:
How does pain affect function?
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Clinical Examination
• List results of clinical examination
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Results of Further Tests and Examinations
• List test results, if applicable
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Discussion Question
WHAT WOULD BE YOUR DIAGNOSIS FOR THIS
PATIENT?
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Diagnosis
• Describe diagnosis
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Discussion Question
WHAT TREATMENT STRATEGY WOULD YOU RECOMMEND?
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Treatment Plan
• List both pharmacologic and non-pharmacologic components of management strategy
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Follow-up and Response to Treatment(s)
• Describe pain, function, adverse effects, etc. at next visit
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Case Template: Discussion Question
WOULD YOU MAKE ANY CHANGES TO THERAPY OR
CONDUCT FURTHER INVESTIGATIONS?
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Other Investigations
• List results of further investigations, if applicable
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Changes to Treatment
• Outline changes to therapy, if applicable
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Conclusion
• Describe pain, function, adverse effects, etc. at next visit
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What If Scenarios
• How would your diagnosis/treatment strategy change if…– List what if scenarios